A Medicare non-participating (non-PAR) provider's approved payment amount is $200 for a lobectomy and the deductible has been met. Which of the following amounts is the limiting charge for this procedure?

Prepare for the NHA Certified Billing and Coding Specialist (CBCS) Exam with engaging quizzes. Study with multiple choice questions, each offering hints and explanations, to enhance your understanding and readiness for the exam!

Multiple Choice

A Medicare non-participating (non-PAR) provider's approved payment amount is $200 for a lobectomy and the deductible has been met. Which of the following amounts is the limiting charge for this procedure?

Explanation:
Limiting charge is the maximum a non-participating Medicare provider can bill a beneficiary for a covered service. For non-PAR physicians, this cap is 115% of the Medicare-approved amount. With an approved amount of $200, the limit is 200 × 1.15 = $230. The deductible being met affects how much the patient still owes in coinsurance, but it does not change the limiting charge. So the maximum amount the non-PAR provider could bill for this lobectomy is $230.

Limiting charge is the maximum a non-participating Medicare provider can bill a beneficiary for a covered service. For non-PAR physicians, this cap is 115% of the Medicare-approved amount. With an approved amount of $200, the limit is 200 × 1.15 = $230. The deductible being met affects how much the patient still owes in coinsurance, but it does not change the limiting charge. So the maximum amount the non-PAR provider could bill for this lobectomy is $230.

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